529

Dermatol Clin 23 (2005) 529– 535

Reduction Structured Rhinoplasty

Thomas Romo III, MDa,b,c,*, Benjamin G. Swartout, MD d

aDivision of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, The New York Eye and Ear Infirmary, 310 East 14th Street, New York, NY 10003, USA bDivision of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, Lenox Hill Hospital, 100 East 77th Street, New York, NY 10021, USA cFacial Plastic and Reconstructive Surgery, 135A East 74th Street, New York, NY 10021, USA dDepartment of Otolaryngology–Head and Neck Surgery, New York University, 550 First Avenue, New York, NY 10016, USA

The philosophy of corrective and aesthetic surgery the 1930s the most popular type of rhinoplasty was the of the external nose has evolved over the last several Joseph reductive rhinoplasty. Although this technique decades. Historically, facial plastic surgeons had a typically produced cosmetically favorable immediate limited understanding of nasal structure and of the postoperative results, it often damaged the structural long-term effects of wound healing. Often, immediate integrity of the nose and caused patients to develop postoperative results were cosmetically pleasing, but functional disturbances years later. In addition, during the structural integrity of the nose was lost. In some the healing process, as the tissues contracted over this cases, structurally compromised noses collapsed on weakened nasal structure, patients frequently inspiration, leading to nasal blockage. During the developed cosmetic deformities and asymmetries. healing process, the skin tightened and often buckled Despite these issues, this model of the reductive this weakened framework, leading to asymmetries and rhinoplasty technique continues to be performed in deformities. Over the last few decades facial plastic many centers as the preferred method even to this day. surgeons have leveraged advancements in the understanding of wound healing and nasal structure to As surgeons began to recognize adverse effects in develop improved tissue rearrangement techniques. some of their patients, surgical strategies were When coupled with structural reinforcement, these developed to prevent these outcomes. A particularly new techniques can be performed to maintain or im- significant development in the 1970s was Jack prove nasal respiratory function, ensure long-lasting Sheen’s introduction of the first shield tip graft to structural stability, and achieve an aesthetically pleas- address the problem of an overresected nasal tip. This ing cosmetic result. This discussion describes some of technique marked a departure from previous norms in the new techniques. its integration of more advanced nasal structure knowledge. It has since been adopted for application in some primary cases as a means of increasing the projection and definition of the nasal tip. Other History structural support techniques that have become more popular include columellar struts, dorsal onlay grafts, batten grafts, and spreader grafts. A few of these Rhinoplasty is considered one of the most chal- techniques are described in the following sections. lenging of all plastic surgery procedures. When the procedure is properly performed, the surgeon reposi- tions the nasal framework to alter aesthetic contours and to maintain or improve respiratory function. In Preoperative evaluation * Corresponding author. Facial Plastic and Reconstructive Surgery, 135A East 74th Street, New York, NY 10021. E- When evaluating a patient interested in aesthetic facial mail address: [email protected] (T. Romo III). surgery, a thorough history and physical

0733-8635/05/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.det.2005.03.001 derm.theclinics.com 530 examination are essential. In the initial evaluation, evaluation. The nose should be seen as one of many discussion should begin by focusing on the patient’s aesthetic facial subunits that must interrelate with the motivation for and goals of aesthetic facial surgery. other subunits in a balanced and harmonious manner The surgeon should help the patient develop realistic [1]. expectations with a frank discussion of the limitations To aide in examining the symmetry and balance of of the proposed procedures. Adverse outcomes the face, the face should be divided into thirds. Each should also be discussed and the patient should dem- third should be roughly equal in vertical dimension, onstrate an understanding of these risks. as shown in Fig. 1. The face should also be divided horizontally into fifths. Each fifth should ideally be the width of the eye, and any deviations from this Patient history may indicate asymmetries or altered proportions (Fig. 2) [2]. The surgeon should focus on the chief complaint to The nose commands a prominent position in the develop a clear understanding of the patient’s center of the face and has major influence on the concerns. The patient should begin by describing aesthetics of the face. On profile, the vertical height what aesthetic characteristics are the most concern- of the nose (from the nasion to the nasal root) should ing, often with the help of a mirror or specially de- be 43% of the distance from the nasion to the menton signed computer imaging software. A history of nasal (Fig. 3). symptoms should be discussed including the presence Lines and angles created by the nose can be used to of right, left, or bilateral obstruction; fixed or analyze further the position and orientation of the changing obstruction; rhinorrhea; epistaxis; or sinusi- nose. The nasofrontal angle should be 125 to 135 tis. Any history of trauma should be further explored. degrees (Fig. 4). The nasolabial angle should be Any prior nasal procedures, especially septoplasty, about 90 degrees in men and between 95 and 105 should be known before surgery because this infor- degrees in women (Fig. 5). This is the major mation may guide surgical planning. determinant of tip rotation or ‘‘attitude’’ of the tip. Shorter people can tolerate more tip rotation than In addition to a full exploration of the patient’s past taller people. medical history, any personal or family history of bleeding should be noted and may require further On lateral view there should be at most 4 mm of laboratory investigation. In patients who smoke, the columella visible and on frontal view the infratip surgeon should insist that they refrain before surgery to lobule and ala should create a line similar to a ‘‘gull achieve the best results. The risks of smoking on in flight.’’ The nasal width should be equal to one postoperative wound healing should be clearly stated intercanthal width at the alar base. The basal view of and the patient must demonstrate an understanding of the nose should approximate an equilateral triangle these risks. A history of drug use, especially cocaine, with a columella to lobule height of 2:1. The ideal tip should be noted. A history of collagen vascular dis- width is 70% to 75% of the base width. eases, though rare, should be known before surgery because it may impact the expected results. The projection of the nose is a description of how far anteriorly the tip of the nose projects from the All medication taken by the patient should be face. It is evaluated on profile by measuring the documented, especially topical nasals sprays, sys- distance on a horizontal line drawn through the alar temic decongestants, antihistamines, steroids, and crease perpendicular to the Frankfurt plane. The anticoagulants. If a patient takes aspirin, ibuprofen, or high-dose vitamin E he or she should discuss discontinuing these medications with his or her primary care physician before surgery. The surgeon should inquire as to the use of herbal medications, especially the ‘‘four G’s’’ (ginseng, garlic, Ginkgo biloba, and ginger), which are known to produce an anticoagulant effect.

Physical examination

An overall evaluation of the face emphasizes balance and symmetry and begins with a frontal facial Fig. 1. Horizontal frontal thirds. 531

thickness skin is ideal and likely to produce the best aesthetic results.

Fig. 2. Vertical fifths. length of a horizontal line drawn from the nasal tip to the alar line divided by the length of a line drawn from the nasion to the nasal tip should be between 0.55 and 0.60 (Fig. 6).

The skin quality of the nose should be examined and may guide the surgical planning. Thick skin is rich in sebaceous glands. Surgeons should avoid the temptation to overreduce this type of nose to achieve a small, well-defined nose, because more often this produces a small, poorly defined ‘‘bag of potatoes’’ nose. Thin-skinned noses can also be quite challenging. Although it is easier to achieve good definition with thin skin, minor imperfections are more visible. In addition, thin skin is prone to increased postoperative contractions leading to an unnatural, ‘‘shrink-wrapped’’ appearance. Medium

Fig. 3. Nasal height. Fig. 5. Nasolabial angle. 532

Fig. 4. Nasofrontal angle.

The nose should be examined by inspection and palpation. Any wrinkles, dryness, or sun damage should be noted. An internal nasal examination should include direct inspection with a nasal speculum and possibly fiberoptic nasal examination when warranted. The position of the caudal border of septum should be noted. The surgeon should examine the quality of the mucosa and the size, color, and position of the turbinates. Palpation of the septum helps elucidate structural support. Any septal scar tissue should be noted and may indicate prior surgery. 533

Clinical photography

Standardized preoperative and postoperative pho- todocumentation is essential both in analysis and evaluation of results. This can be done by a medical doctor or qualified medical photographer and should include four views: the anterior full face at mid-neck including the outline of the hair, right and left profile, and basal view. At least one photograph should be taken with the patient smiling. Should the patient have significant asymmetry, a close-up basal view is recommended. Standard photographic technique includes use of adequate lighting without excessive shadowing. The patient should be at least 1 m from the camera and at least 1 m from a dark background. Photodocumentation of this type contributes to the continued refinement in surgical planning and tech- nique of even the most experienced plastic surgeon. Photodocumentation can also form a teaching file in an academic setting and can become a part of the Fig. 6. Nasal projection. medical and medicolegal record.

A septal perforation, if found, should be evaluated in size, location, and etiology. Radiologic and laboratory evaluation The nasal tip support should be evaluated by palpation. Depressing the nasal tip and watching for Radiography is indicated when the history suggests ‘‘tip recoil’’ helps assess the underlying cartilaginous recurrent or chronic sinus disease or as other-wise framework and may guide the extent of cartilage warranted. Typical preoperative laboratory resection. The strength of the alar cartilage should investigation includes SMA-7, complete blood count, also be evaluated by palpation. Ballottement of the urinalysis, prothrombin time and partial thrombo- ala helps assess structural integrity and may guide the plastin time, and in patients over the age of 45 or extent of resection or indicate a need for structural with significant cardiac history a chest radiograph reinforcement. These examinations may also indicate and ECG. the need for structural reinforcement. Nasal respiratory function should be evaluated using the cottle test both before and after deconges- Preoperative discussion tion with a topical spray. A small spatula is used to support the nasal valve and the patient is instructed to It is imperative that the surgeon clearly delineates obstruct the opposite nostril and inhale. The patient the limitations of the proposed procedure. One of the rates the nasal patency with and without the support most common reasons for dissatisfaction among of the spatula. This is done to evaluate the internal facial plastic surgery patients occurs when there is and external nasal valve and repeated on the opposite discordance between the expectations of the patient side. The patient is then fully decongested and is and surgeon. The Step Theory may facilitate this asked to rate the patency of each side. This exami- discussion (Fig. 7). In this theory a patient can rate nation helps evaluate for nasal valve collapse and his or her preoperative appearance on a scale of 1 to may indicate the need for structural reinforcement. In 5 with a 1 being perfection and a 5 being a mon- patients with nasal obstruction responsive only to strosity. A reasonable expectation is to improve by decongestion, a turbinectomy should be considered. one level, at most two levels. The surgeon must stress that perfection is not a realistic goal and only leads to The external nasal bones should be evaluated by disappointment. inspection and palpation. Asymmetries should be noted as should the width and projection. The internal The surgeon should provide an overview of the nasal bones should be examined by palpation. Any healing process including a timeline. Sample photo- deviation of the perpendicular plate of the ethmoid graphs can aide in this discussion. By adequately should be noted. preparing for the process, patients often feel more in 534

The patient should shampoo with a hexachlorophene detergent cleanser (pHisoHex) the evening before surgery.

Surgical planning

The surgical planning for each case should be tailored to the unique deformities and functional prob- lems presented. The surgeon should consider the aesthetic goals of the patient, including cultural, so- cial, and ethnic aspects that may influence the desired outcome. General goals should include the improve- Fig. 7. The step theory. ment of nasal respiratory function; preservation or augmentation of the nasal support structures; maximal esthetic improvement; and avoidance of septal control during the healing period. Immediately after perforation, stenosis, and scarring. the surgery the patient has puffy eyes and they may be black and blue. There is a bandage over the nasal The surgeon should study all the patient informa- bridge and there may be packing inside the nose. This tion and should fully describe the problems. The packing is removed either after the patient fully anatomic cause of each of these problems should then awakes from anesthesia or the following day. When be deciphered. The appropriate surgical maneuvers the packing is in place the patient is not able to breathe should then be decided on and the sequence of events through his or her nose. Self-care should be explained should be planned. Typically, a surgeon visualizes this including the use of cold-compresses across the nasal procedure five times on a given patient: (1) in the bridge. Various stages of healing should be explained office while examining the patient, (2) during preop- including when the final post-operative results can be erative planning, (3) during the actual procedure, (4) evaluated. during immediate postoperative care, and (5) when evaluating the results at 6 months. It must be Potential complications should be described in a remembered that a surgeon cannot judge the results at balanced, accurate, and appropriately descriptive a given time, but rather should see the results as an manner. Risks of both minor and more significant evolving process that changes throughout the patient’s postoperative bleeding should be explained including life. the patient’s role in preventing or stopping the bleeding at home. Depending on the procedure, the risks of visible intranasal or external scarring should be explained. The use of cosmetic products in this Anesthesia situation can be explained. Should the patient require scar revision, this should also be described. Risks of Rhinoplasty can be performed effectively under nasal obstruction or valve collapse should be ad- either local or general anesthesia. Regardless of the dressed and possible revision procedures can be ex- type chosen, successful anesthesia relies on close plained at this point. More serious adverse outcomes cooperation between the anesthesiologist and surgeon. including cerebrospinal fluid leak, meningitis, and Just as the surgeon expects to be updated on death should be mentioned, appropriately weighted by significant changes in the cardiovascular status of a their relative rarity. patient, so does the anesthesiologist expect to be informed of what concentration and volume of epi- Beyond revision surgery for adverse outcomes, the nephrine is being injected, or if the endotracheal tube possibility of further touch-up surgery for minor is being adjusted. imperfections may be warranted. The fee, if any, should be disclosed. The surgeon should consider Local anesthesia combined with premedication or having a patient write out the risks of surgery in his or light sedation has been successfully used by many her own words. This facilitates further discussion, facial plastic surgeons, but should be used only in a helps verify understanding, and may provide medi- motivated patient able to cooperate during this colegal protection for the surgeon. moderately uncomfortable procedure. Patients benefit The surgeon should give the patient a list of from this choice of anesthesia by a hastened recovery anticoagulants that should not be taken for 2 weeks and reduced cost. There are some drawbacks, how- before surgery. Prescriptions for postoperative med- ications should be given at this visit and explained. 535 ever, to this technique. When sedated, an uncomfort- anatomic distortion. Use a long 27-gauge needle, able patient may become so restless that the taking care to inject into the proper plane. This procedure must be aborted or converted to general produces hydrodissection, lifting up the tissue within anesthesia. In addition, this technique does not pro- the plane, allowing for ease of surgical dissection. vide airway protection and puts the patient at risk for Injecting into the proper plane also more effectively aspiration when under sedation. Some surgeons reduces bleeding and allows the surgeon to use less advocate general anesthesia with an endotracheal anesthetic agent. This minimizes distortion of tissues tube. Although this does provide good airway pro- and exposes the patient to less medication. Forceful tection, it irritates the glottis, leaving a patient with a injections should be made in the submucoperichon- sore throat and often hoarse voice after surgery. The drial and submucoperiosteal planes on septum pro- best anesthetic choice, then, for many patients is se- ducing a hydraulic elevation of the flap. Injections dation and placement of a laryngeal mask tube. Al- should also be made along the hemitransfixion and though some authors believe that the laryngeal mask rim incision sites. The nasal apex should be injected, tube obscures the view of the patient profile and in- and between the domes and the inferior turbinates. terferes with access to the base of the nose, the The surgeon should next inject the supraperichondrial authors’ experience has shown that if the tube is not space of the upper and lower lateral cartilage, the taped, then it can easily be positioned to provide ac- supraperiosteal space over nasal bones, and the cess to and visualization of these areas. extraperiosteal planes on maxilla along the proposed osteotomy sites. Following the injection, the surgeon should wait 10 to 15 minutes before making incisions to allow for maximal effect of the epinephrine. Surgical technique If during the course of the procedure bleeding Immediately preoperatively the patient should be becomes excessive or uncontrollable the nose should examined while awake and sitting up. At this time the be packed with sponges soaked in a vasoconstricting surgeon should mentally visualize the procedure agent and the surgeon should wait 5 to 10 minutes. based on the predetermined plan, verifying the physi- The blood pressure should be checked. If it is found cal examination. to be elevated, appropriate treatment should be insti- tuted. Any bleeders should be identified and cau- Once in the room, the patient should be positioned terized. A bleeding site can be injected with lidocaine supine on the operating table. Preoperative photos and epinephrine or treated with a cottonoid soaked should be arranged for easy access throughout the with a vasoconstrictor. If the bleeding continues, procedure. Surgical landmarks should be noted by microfibrillar collagen, also known as ‘‘witch’s hair,’’ palpation and labeled with a surgical marking pen. can be used, although this makes it more difficult to These may include the margins of the upper and continue the procedure. If all these efforts fail, the lower lateral cartilage, the tip defining point, any surgeon should consider placing a formal pack and planned cephalic reduction, the extent of any bony aborting the procedure. cartilaginous hump reduction, and intended sites of osteotomy. The septum should be addressed first. A full Local anesthesia should be given, even with transfixion incision is made for septal harvesting general, to allow for a lighter plane of anesthesia. (Fig. 8). After raising the mucoperichondrial flap on Neurosurgical cottonoids soaked with Neosynephine hydrochloride or color-coded 4% cocaine should be placed intranasally. Many texts describe discrete anatomic sites to target specific nerves, but this concept is purely academic in nature and not of practical use.

For the injectable agent the authors prefer 1% lidocaine with 1:100,000 epinephrine. The authors consider 1:500,000 epinephrine for an elderly patient with cardiac disease. In general, approximately 5 to 8 mL should be sufficient to anesthetize the nose. Keep in mind that the maximum dose of lidocaine is 7 mg per kg or 500 mg in an average adult. This is approximately 50 mL of 1% lidocaine. When in- jecting an anesthetic agent it is essential to avoid Fig. 8. Full transfixion incision. 536

Fig. 9. Harvesting the nasal septum. Fig. 11. Resection of caudal septum mucoperichondrium.

one side of the nasal septum, an incision is made is elevated off the lower lateral cartilage, then the through the septum posterior to the anterior septal upper lateral cartilage. This can also be done sharply angle to form the anterior septal strut. This incision with a scalpel. This flap should be elevated laterally continues to the floor of the nose and this window of just enough to provide access to that particular nose. cartilage is removed and placed aside in saline (Fig. Elevation continues to the nasal bones where the 9) [3]. periosteum is incised. The periosteum is then elevated The nose can then be shortened by reducing the off the nasal bones using a Joseph elevator [4]. caudal septum (Fig. 10). This also corrects the septal angle and should be accompanied by an adequate Attention should then be directed to the dorsal resection of mucoperichondrium (Fig. 11). This re- hump. The dorsum should be reduced to a line pre- section may include a portion of the bony nasal spine, determined by the preoperative analysis. To facilitate which can be taken using a rasp or an osteotome. dissection and modeling of the cartilaginous dorsum, After completion of the septal work the transfixion the upper lateral cartilages are separated from the incision is closed. septum. This can be done by creating a submucosal tunnel and, with an Aufricht retractor in place, a The external approach is most commonly used and number 11 scalpel is used to incise upward, cutting begins with degloving the nasal tip and dorsum. An the connections between the upper lateral cartilage inverted V incision is made at the columella and and the septum. Care should be taken to avoid pene- continued laterally as the standard ‘‘gullwing’’ (Fig. trating the nasal mucosa during this step. Separating 12). This incision continues along the marginal the upper lateral cartilages from the septum can also inferior edge of the lower lateral cartilage. Care be accomplished using the ‘‘squeeze down’’ tech- should be taken to elevate the soft tissue over the nique where a scissor is used to resect the cartilagi- cartilaginous dorsum. Using tip scissors, the skin flap nous dorsum. Once the upper lateral cartilages are

Fig. 10. Resection of the caudal septum. Fig. 12. Dorsal view of gullwing incision.